Comparison of Postoperative Outcomes of TURP, Laser Vaporization and Laser Enucleation: A Double Propensity Score Matched Analysis

Benign prostatic hypertrophy (BPH) is a common pathology in aging men that has increased in incidence over the years. This condition has been shown to be asymptomatic in some men but has also been shown to result in benign prostatic obstruction; hence, introducing lower urinary tract symptoms and a decreased quality of life. Transurethral resection of the prostate (TURP) has long been considered the gold standard surgical intervention for managing symptomatic BPH. However, recent advancements in surgical techniques have introduced novel laser approaches, including laser vaporization (LVP) and laser enucleation (LEP), which offer promising alternatives to traditional TURP.

To compare the postoperative outcomes of these 3 different types of endourologic surgeries for BPH treatment, we conducted a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. We compared pre-operative characteristics, medical comorbidities and events, and post-operative outcomes. To control for possible confounders and as a sensitivity analysis, we performed a multivariate analysis and propensity score matching.

A total of 74,273 patients underwent endourologic surgeries between 2011 and 2019 of whom 48,609 (65.4%) had undergone TURP, 21,271 (28.6%) had LVP, and 4,393 (5.9%) had undergone LEP. Patients who underwent TURP were found to be older, with a higher ASA class, more likely to have abnormal labs, and more likely to have comorbidities such as diabetes, insulin dependent diabetes, and bleeding requiring transfusion. After controlling for confounders, LVP showed shorter operative times (-0.92 mins), shorter length of stay (-3.27 days), lower odds of bleeding transfusion (OR=0.21), PE/DVT (OR=0.52), MACE (OR=0.76), and readmissions (OR=0.64), and higher odds of UTI (OR=1.15) as compared to TURP (p-value <0.041). On the other hand, LEP showed longer operative times (39.1 mins), shorter length of stay (-0.46 days), and lower odds of UTI (OR=0.58), bleeding transfusion (OR=0.55), PE/DVT (OR=0.40), MACE (OR=0.38), and readmissions (OR=0.09) (p-value <0.006). In regard to Clavien-Dindo (CD) complications laser techniques showed lower odds of high-grade CD complications as compared to TURP. Furthermore, LVP and LEP showed lower odds of cystourethroscopy with irrigation and evacuation of multiple obstructing clots and resection of prostatic tissue left after a previous surgery as compared to TURP.

Laser techniques have revolutionized the way urologists perform prostatic resection and have provided clear advantages when compared to traditional techniques. It has already been shown that laser techniques provide advantages in terms of bleeding and blood transfusion rates. Furthermore, laser techniques are recommended in patients on oral anticoagulants. Limitations to the widespread use of laser techniques include their availability, cost, and learning curve. However, these techniques do provide clear advantages and could become gold standards in the future.

Written by: Christian Habib Ayoub, MD & Albert El Hajj, MD

Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon

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